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Arthroscopy of the Temporomandibular Joint

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Arthroscopy of the Temporomandibular Joint ® ARTHROSCOPY OF THE TEMPOROMANDIBULAR JOINT Wolfram M. H. KADUK ® ARTHROSCOPY OF THE TEMPOROMANDIBULAR JOINT Prof. Wolfram M. H. KADUK, MD, DDS Consultant Oral, Maxillofacial and Plastic Surgery, Orthodontist and Oral Surgeon Hospital and Outpatient Center for Oral and Maxillofacial Surgery – Plastic Surgery Ernst-Moritz-Arndt University, Greifswald, Germany 4 Arthroscopy of the Temporomandibular Joint Drawings: Arthroscopy of the Temporomandibular Joint The schematic anatomical drawings were made Prof. Wolfram M. H. Kaduk, MD, DDS by Mrs. Katja Dalkowski, M.D., Consultant Oral, Maxillofacial and Plastic Surgery, Grasweg 42, D-91054 Buckenhof, Germany Orthodontist and Oral Surgeon E-mail: [email protected] Hospital and Outpatient Center for Oral and Maxillofacial Surgery – Plastic Surgery Ernst-Moritz-Arndt University, Greifswald, Germany Correspondence address of the author: Prof. Dr. med. Dr. med. dent. Wolfram M. H. Kaduk Facharzt für Mund-Kiefer-Gesichtschirurgie / Plastische Operationen, Kieferorthopäde, Oralchirurg Klinik und Poliklinik für Mund-Kiefer-Gesichtschirurgie / Plastische Operationen Universitätsklinikum der Ernst-Moritz-Arndt-Universität, Important notes: Greifswald, Germany Sauerbruchstr./Bettenhaus I Medical knowledge is ever changing. As new research and clinical 17487 Greifswald, Germany experience broaden our knowledge, changes in treatment and therapy Phone: 0049 (0) 3834 86 7160 may be required. The authors and editors of the material herein have Fax: 0049 (0) 3834 86 7316 consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards E-mail: [email protected] accept ed at the time of publication. 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ISBN 978-3-89756-122-9 Arthroscopy of the Temporomandibular Joint 5 Table of Contents 1.0 Introduction . 6 2.0 Our Protocol for the Treatment of TMJ Disc Displacements . 7 3.0 Diagnostic Arthroscopy of the Temporomandibular Joint . 8 3.1 Indications and Contraindications . 8 3.2 Preoperative Preparations, Draping,| and Instrumentation . 8 3.3 Arthroscopic Approach to the Temporomandibular Joint . 9 3.4 Instrument Use, Description of Findings and Documentation . 10 4.0 Minimally Invasive Arthroscopic Treatment of Disk Displacement and Elongation of the Retrodiscal Tissue Combined with Diagnostic Arthroscopy. 14 4.1 Shortening the Retrodiscal Tissue with a Water-Jet Scalpel. 14 4.2 Aftercare and Complications of Water-Jet Treatment . 15 4.3 Other Arthroscopic Treatment Options (Nd:YAG and Holmium:YAG Lasers, Electrosurgery) . 15 4.4 Arthroscopic Fixation Techniques –| An Additional Therapeutic Options . 16 4.5 TMJ Arthroscopy and Surgical| Navigation . 16 5.0 Arthroscopic Training in an Animal Model . 17 6.0 The First Temporomandibular Joint Arthroscope with an Integrated Working Channel – Advantages and New Technical Capabilities . 18 7.0 Concluding Remarks. 21 8.0 Recommended Reading. 22 Instruments and Units for the Arthroscopy of the Temporomandibular Joint . 23 6 Arthroscopy of the Temporomandibular Joint 1.0 Introduction The surgical treatment of temporomandibular joint (TMJ) As in all degenerative muscle, bone and joint diseases, disorders presents us with an extremely complex and surgical intervention should be elected sparingly and complicated set of interwoven problems that can raise the primary treatment options are conservative. Surgical diffi cult issues of diagnosis and treatment. treatment is indicated in only about 5% of patients The great diversity of TMJ disorders results from the with TMJ disorders. Because TMJ operations are such overlap between multiple organ systems and numerous specialized procedures, often it takes years to acquire functional processes, as illustrated in Fig. 1. adequate clinical experience. Another factor that limits the indications for TMJ surgery is the miniscule size of the joint (about the size of a thumbnail). As a result, TMJ surgery and especially minimally invasive arthroscopic procedures are more technically demanding than procedures in larger joints, which are easier to access and explore. A major obstacle in mastering arthroscopic skills is the fact that operators cannot practice in human patients, while practicing in cadavers may do little to impart clinically relevant skills due to the altered consistency and appearance of the nonperfused tissues. At our institution in Greifswald, we have solved the problem of safe TMJ arthroscopic training by developing 1 an animal model that enables us to practice and teach a range of minimally invasive arthroscopic procedures The temporomandibular joint and associated disorders. in the TMJ. This is such an effective training tool that technical problems which subsequently arise in patients The following components may also play a role: no longer limit the indications for TMJ arthroscopy. ˾ Craniomandibular dysfunction (CMD) Our objective in creating this guide to TMJ arthroscopy ˾ Cerebral, neurological and psychiatric diseases is to convey the experience that we have gained in ˾ Orthopedic diseases (e.g., of the cervical spine) our training model. Besides the basic principles of ˾ Regulatory dysfunction, overloads, compensatory diagnostic arthroscopy, particular attention is given to processes the arthroscopic use of an innovative water-jet scalpel and to other arthroscopic techniques on the TMJ disc ˾ Age-related changes and retrodiscal tissue. ˾ Decompensation due to changes in activity level or physical situation The simultaneous use of a surgical navigation system helps the operator to proceed more confi dently and will one day make an important contribution to quality Proper patient selection is an essential foundation for assurance in arthroscopic surgery of the TMJ. successful surgical treatment. The principal indications for TMJ surgery are forms of craniomandibular In writing this monograph, we hope that we will be able dysfunction originating in the articular disc and to improve training to such as degree that a greater the retrodiscal tissue (known also as the posterior percentage of patients with TMJ disorders will become attachment, posterior ligaments, or retrodiscal pad). candidates for arthroscopic surgery, thus avoiding The
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